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Waste Tire Sus vey & Inspection Repon Inspection Report Number ■ <br /> CalRecycle State of California I 1 - 1245155 <br /> CalRecycle R cover (CalRecycle) Survey <br /> Survey Form - Page I <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- U Inspection Type(Fill one) <br /> Site Suffix: ` 5 1 5 I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: v\ �, / Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facil•Ity Name ` \' <br /> Inspected By Inspector <br /> Physical Addresso <br /> IoSd <br /> 1 Inspection Date � � / O <br /> 0't'\C> 6A q Z`, Time In Time Out <br /> Business Rep Title 1 O AM { �J O AM <br /> 1 i ` 0 & PM ✓ ! ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ,r� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (� a Active Q Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> ,�� Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 0 OTR Q End-Use 40 Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) n <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> Q Q Other:§ <br /> - - z <br /> Comments a Q — N <br /> a C 2 ✓\ <br /> Inspection Form Included: Q— 0110 9 4A& C. <br /> Comments luded- 0 <br /> Business Rep's Signature Phone Number Inspe or's Signature. Phone Number <br /> �-,( <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: M � NJ IE X A M P L E 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LFA ■ <br />